Declining Surgical Resident Operative Autonomy-All Trainees Are Not Created Equal.

INTRODUCTION: We have previously shown that resident autonomy has decreased over time overall for all surgery residents. The purpose of this study is to examine changes in operative autonomy in general surgery residency within each postgraduate year (PGY) level. MATERIALS AND METHODS: This is a retrospective analysis of the Veterans Association Surgical Quality Improvement Program database from July 1, 2004 to September 30, 2019. All general surgery, vascular surgery, and thoracic surgery procedures were analyzed and categorized by level of resident supervision as attending primary, attending operating with resident, or resident primary without attending scrubbed. Procedure work portion of relative value unit was used to capture procedure complexity. Changes in resident autonomy over time, procedure complexity, and outcomes were compared among PGY levels 1 to 5. RESULTS: A total of 385,482 cases were analyzed. At each PGY level from 2014 to 2018, the relative decrease in resident primary cases ranged from -37.3% (PGY 4) to -75.5% (PGY 3). Mean work portion of relative value unit saw steady increase with PGY level (8.4 ± 3.5 in PGY 1 to 10.8 ± 5.7 in PGY 5, P < 0.001) and did not show a trend over time. CONCLUSIONS: Surgical resident operative autonomy has markedly decreased over time across all PGY levels. This effect is most profound at the PGY 3 level, while more senior residents are affected to a lesser degree. Case complexity show PGY level-appropriate increase in resident autonomous cases. Decrease in resident autonomy over time is not associated with changes in case complexity.

Anterior Abdominal Varicosities Due to Unilateral Common and External Iliac Vein Occlusion Five Decades Post-Injury.

Abdominopelvic varicosities are a rare occurrence after traumatic venous injuries. Several disorders exist that present with abdominopelvic varicosities such as May-Thurner syndrome, pelvic congestion syndrome, and nutcracker syndrome; however, it has rarely been described after trauma.1 We present a case in 70-year-old male, who in 1974 sustained a penetrating injury from fragments secondary to mortar explosion, requiring exploratory laparotomy. He presented to the hospital with abdominopelvic varicosities that began 20 years after the incident and was asymptomatic at initial presentation. While there is a known case report of congenital absence of a common iliac vein in a young, healthy, athletic man who developed abdominopelvic varicosities, this is the first case report, to our knowledge, of evolution of a traumatic injury of this nature over a lifetime. Pathophysiology, diagnostics, risks of ligation, and management of chronic abdominopelvic varicosities in this patient are discussed.

Surgical resident operative autonomy on nights and weekends: What happens to surgical education during off-hours?

BACKGROUND: Surgical resident operative autonomy is critical for trainee maturation to independence. Acute care surgery (ACS) cases commonly occur off-hours and tension between operating room availability and on-call staff can affect resident operative autonomy. We examined operative resident autonomy for general, vascular, and thoracic (GVT) surgery during nights and weekends. We hypothesized that residents would be afforded less operative autonomy during off - hours than weekdays. METHODS: This retrospective cohort study uses the Veterans Affairs Surgical Quality Improvement Program database, we examined all GVT cases at Veterans Affairs teaching hospitals from 2004 to 2019. All cases are coded for the level of supervision at the time of surgery: AP, attending primary surgeon; AR, attending and resident operating together; and RP, resident primary (attending supervising but not scrubbed). Cases starting between 6 pm to 7 am Monday through Friday were considered nights, cases on Saturday/Sunday were considered weekends, and collectively considered "off-hours." Resident primary case rates were compared by start time and type. RESULTS: Over the 15-year study period, there were 666,421 GVT cases performed with 38,097 cases (6%) performed off-hours. During off-hours, 31,396 (83%) were ACS compared with 5% of daytime cases. Overall, off-hours cases have higher RP rate than daytime cases (6.8% vs. 5.8%, p < 0.001). Daytime ACS cases have higher rates of RP than nights/weekends (7.6% vs. 6.8%, p < 0.001). Conversely, daytime elective cases have lower RP than nights (5.7% vs. 7.9%, p < 0.001). During off-hours, there are more RP cases on nights compared with weekends (7.1% vs. 6.5%, p = 0.02). CONCLUSION: Overall, residents were afforded more operative autonomy during off-hours, with nights having greater RP than weekends. In contrast, ACS cases have more autonomy during weekdays. These data have potentially significant implications for ACS service staffing, night float rotations, and overall resident operative experience on ACS services. LEVEL OF EVIDENCE/STUDY TYPE: Prognostic and Epidemiological; Level III.

Conservative Management of Large Tracheal Perforation due to Traumatic Intubation.

Tracheal perforation is a rare complication of intubation and is associated with high mortality. Here we describe a case of large, full-thickness tracheal perforation from traumatic intubation after an elective procedure. The injury was managed with prolonged intubation that bypassed the site of injury, and the patient was successfully extubated after 11 days. Conservative management of tracheal perforation after traumatic intubation is an option in select patients that avoids need for surgery.

Increasing volume but declining resident autonomy in laparoscopic inguinal hernia repair: an inverse relationship.

INTRODUCTION: With improved technology and technique, laparoscopic inguinal hernia repair (LIHR) has become a valid option for repairing both initial and recurrent inguinal hernia. Surgical residents must learn both techniques to prepare for future practice. We examined resident operative autonomy between LIHR and open inguinal hernia repair (OIHR) across the Veterans Affairs (VA) system. METHODS: Utilizing the VA Surgical Quality Improvement Program database, we examined inguinal hernia repairs based on the principal procedure code at all teaching VA hospitals from July 2004 to September 2019. All VA cases are coded for level of supervision at the time of surgery: attending primary surgeon (AP); attending scrubbed but resident is a primary surgeon (AR), and resident primary with attending supervising but not scrubbed (RP). Primary outcomes were the proportion of LIHR versus OIHR and resident autonomy over time. RESULTS: A total of 127,497 hernia repair cases were examined (106,892 OIHR and 20,605 LIHR). There was a higher proportion of RP (8.7% vs 2.2%) and lower proportion of AP (23.9% vs 28.4%) within OIHR compared to LIHR (p < 0.001). The overall proportion of LIHR repairs increased from 9 to 28% (p < 0.001). RP cases decreased for LIHR from 9 to 1% and for OIHR from 17 to 4%, while AP cases increased for LIHR from 16 to 42% and for OIHR from 18 to 30% (all p < 0.001). For RP cases, mortality (0 vs 0.2%, p > 0.99) and complication rates (1.1% vs. 1.7%, p = 0.35) were no different. CONCLUSIONS: LIHR at VA hospitals has tripled over the past 15 years, now compromising nearly one-third of all inguinal hernia repairs; the majority are initial hernias. Despite this increase, resident autonomy in LIHR cases declined alarmingly. The results demonstrate an urgent need to integrate enhanced minimally invasive training into a general surgery curriculum to prepare residents for future independent practice.

Declining Surgical Resident Operative Autonomy in Acute Care Surgical Cases.

INTRODUCTION: Surgical resident operative autonomy has decreased markedly over time, reducing resident readiness for independent practice. We sought to examine operative resident autonomy for emergency acute care surgery (ACS) compared to elective cases and associated patient outcomes at veterans affairs hospitals. METHODS: The Veterans Affairs Surgical Quality Improvement Program database was queried for ACS cases (emergency general, vascular, and thoracic) at veterans affairs hospitals from 2004 to 2019. Cases are coded prospectively for the level of supervision: attending primary surgeon (AP); attending scrubbed with resident surgeon (AR); resident primary (RP), attending not scrubbed. Baseline demographics, operative variables, and outcomes were compared. RESULTS: A total of 61,275 ACS cases and 605,146 elective cases were performed during the study period. The ACS had a higher proportion of RP cases (7.2% versus 5.7%, P < 0.001). The proportion of ACS RP cases decreased from 9.9% to 4.1% (58.6%); elective RP cases decreased from 8.9% to 2.9% (67.4%). The most common ACS RP surgeries were appendectomy, amputations, and cholecystectomy. RP cases had lower American Society of Anesthesia class and lower median work relative value units than AP and AR. There was no difference between mortality rates of RP compared to AP (adjusted odds ratio [OR] 0.94 [0.80-1.09] or AR 0.94 [0.81-1.08]). While there was no difference in complications between the RP and AP (OR 1.01 [0.92-1.12]), there were significantly more complications in AR compared to RP (OR 1.20 [1.10-1.31]). CONCLUSIONS: More autonomy is granted for ACS cases compared to elective cases. While both decreased over time, the decrease is less for ACS cases. Resident autonomy does not negatively impact outcomes, even in emergent cases.

Patient inequities in affording surgical resident operative autonomy at Veterans Affairs teaching hospitals, does it extend to female patients?

BACKGROUND: Examining surgical resident operative autonomy within the Veterans Affairs (VA) System, we previously showed residents were afforded autonomy more frequently on Black patients. We hypothesized that, compared to males, female surgical patients receive less attending involvement and more resident autonomy during surgery. METHODS: Retrospective review of all general/vascular surgeries performed at teaching VA hospitals from 2004 to 2019. Operative procedures are coded at the time of surgery as attending primary surgeon (AP), attending with resident (AR), or resident primary surgeon--attending not scrubbed (RP). The primary outcome was the difference in supervision rates between patient sexes. RESULTS: 618,578 operations were examined-24.9% AP, 68.9% AR, and 6.2% RP. Overall, 5.9% of cases were performed on women. The rate of RP cases was higher in males compared to females (6.3% vs 5.3%, p < 0.001). CONCLUSION: Female veterans are less likely to have residents operate on them autonomously. Reasons for this require further characterization.

General Surgery Resident Complement and Operative Autonomy - Size Matters.

OBJECTIVE: Operative autonomy has progressively decreased for surgery residents. This study investigates the effect of general surgery resident complement size at Veterans Affairs (VA) hospitals on operative autonomy for the residents. We hypothesize that smaller complements of residents would result in fewer opportunities for operative autonomy. DESIGN: Retrospective analysis of the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. SETTING: Operative cases within the VASQIP database from July 1, 2004 to September 30, 2019 were analyzed. PARTICIPANTS: All general surgery procedures performed at teaching VA hospitals from January 2004 to September 2019 were included. The level of resident operative autonomy is defined as follows: attending primary surgeon with or without a resident (AP), resident primary surgeon with attending scrubbed (AR), and resident primary without attending scrubbed (RP). Resident complement is based on funded resident positions at each VA hospital during the academic year 2017-2018 and stratified into 3 groups: small (≤4), medium (>4-<7), and large (≥7). The primary outcome was the proportion of operative autonomy for each resident complement group. Secondary outcomes were level of autonomy over time, and mortality and morbidity for RP procedures. Categorical data were compared with Chi-squared test. RESULTS: Four hundred sixty-one thousand seven hundred thirty-four procedures across 92 VA hospitals with general surgery residents were included in the analysis. There were 126,062 cases performed at 29 small resident complement hospitals, 135,539 at 28 medium resident complement hospitals, and 200,133 at 35 large resident complement hospitals. The percentage of RP procedures was higher with increasing resident complement (2.1% vs 6.8% vs 9.9%, p < 0.001). RP procedures have decreased over time in all groups, but the relative decrease was less pronounced as resident complement increased (79.5% vs 73.3% vs 64.7%, p < 0.001). There was no significant difference in adjusted 30-day all-cause mortality between groups. CONCLUSIONS: Increased resident complement at VA hospitals is associated with increased resident autonomy in resident primary procedures. Resident autonomy has decreased over time regardless of complement size, but it is less dramatic at sites with more residents. Increasing resident complement at a site may improve operative autonomy, leading to an improved educational experience for surgical residents.

Reprogrammed Schwann Cells Organize into Dynamic Tracks that Promote Pancreatic Cancer Invasion.

Nerves are a component of the tumor microenvironment contributing to cancer progression, but the role of cells from nerves in facilitating cancer invasion remains poorly understood. Here we show that Schwann cells (SC) activated by cancer cells collectively function as tumor-activated Schwann cell tracks (TAST) that promote cancer cell migration and invasion. Nonmyelinating SCs form TASTs and have cell gene expression signatures that correlate with diminished survival in patients with pancreatic ductal adenocarcinoma. In TASTs, dynamic SCs form tracks that serve as cancer pathways and apply forces on cancer cells to enhance cancer motility. These SCs are activated by c-Jun, analogous to their reprogramming during nerve repair. This study reveals a mechanism of cancer cell invasion that co-opts a wound repair process and exploits the ability of SCs to collectively organize into tracks. These findings establish a novel paradigm of how cancer cells spread and reveal therapeutic opportunities. SIGNIFICANCE: How the tumor microenvironment participates in pancreatic cancer progression is not fully understood. Here, we show that SCs are activated by cancer cells and collectively organize into tracks that dynamically enable cancer invasion in a c-Jun-dependent manner. See related commentary by Amit and Maitra, p. 2240. This article is highlighted in the In This Issue feature, p. 2221.

Management of Complex Transmediastinal Stab Wound With Cardiac, Esophageal, and Arterial Injury.

Penetrating transmediastinal traumatic injuries often carry a high mortality given the vital structures this type of injury often involves. Here, we describe a case of 24-year-old man who suffered multiple stab wounds to the chest and back with associated cardiac, esophageal, and arterial injury, requiring immediate operative intervention. He underwent sternotomy and left thoracotomy with pericardiotomy, repair of 2 right ventricular lacerations, and ligation of internal mammary artery. The esophageal injury was repaired with endoscopic clips. Patient had an uncomplicated recovery. Despite high mortality often associated with transmediastinal penetrating injuries, good outcomes are achievable with rapid identification of injuries and appropriate operative intervention alongside adequate resuscitation.

Renoduodenal Fistula Following Penetrating Abdominal Injury.

Renoduodenal fistula is an uncommon occurrence and usually results as a complication of injury or inflammatory process. Here, we describe a case of renoduodenal fistula formation after traumatic injury via gunshot wound to the abdomen. The patient suffered right renal and ureteral injury, complicated by urine leak, managed by surgery, interventional radiology, and urology. His post-hospital course was complicated by recurrent urinary tract infections and was found to have a renoduodenal fistula 3 months after the initial operation. Patient underwent uncomplicated right nephrectomy and repair of fistula. Etiology, presentation, diagnosis, and treatment options of renoduodenal fistula are discussed.

Systemic Thrombolysis as Initial Treatment of COVID-19 Associated Acute Aortoiliac and Lower Extremity Arterial Thrombosis.

SARS-CoV-2 (COVID-19) patients with associated thromboembolic events have demonstrated poor outcomes despite the use of anticoagulation therapy and surgical intervention. We present a COVID-19 patient with acute limb ischemia, secondary to extensive thrombosis of an aortic aneurysm, iliac arteries, and infrainguinal arteries. Initial treatment with systemic thrombolysis, which restored patency of the aortoiliac occlusion, was followed by open thrombectomies of the infrainguinal occlusions.

The impact of adenotonsillectomy on pediatric asthma.

OBJECTIVE: To determine asthma outcomes in children undergoing adenotonsillectomy (T&A) for treatment of sleep-disordered breathing (SDB). HYPOTHESIS: Asthmatic children will demonstrate improvement in asthma control after T&A compared to asthmatic children not undergoing surgical treatment. STUDY DESIGN: Prospective cohort. PATIENT-SUBJECT SELECTION: 80 children with diagnosed asthma, aged 4-11, undergoing T&A and 62 controls matched to the T&A subjects by age, sex, and asthma severity classification. METHODOLOGY: Parents and children completed the Childhood Asthma Control Test (C-ACT) and the Pediatric Sleep Questionnaire (PSQ). Parents were queried regarding the number of asthma exacerbations, the frequency of the use of systemic steroids, the number of emergency room visits and the number of hospitalizations in the prior 6 months. The identical questionnaires and interviews were completed 6 months after entry. RESULTS: The adjusted mean (95% CI) C-ACT score was 21.86 (20.94-22.68) at entry and 25.15 (24.55-25.71) at follow-up for the T&A group compared with 22.42 (21.46-23.28) and 23.59 (22.77-24.33) for the control group. There was a significant group by time interaction (P < 0.001). Simple effects analysis showed that group means did not differ at entry (P = 1.00) but did differ at follow-up (P = 0.006). Baseline PSQ was a significant predictor of improvement in C-ACT scores. Statistical modeling did not demonstrate significant group by time interactions for any of the asthma clinical outcomes, although these outcomes were very infrequent in both groups. CONCLUSION: Treatment of SDB improves asthma outcomes as measured by the C-ACT.

An In Vivo Murine Sciatic Nerve Model of Perineural Invasion.

Cancer cells invade nerves through a process termed perineural invasion (PNI), in which cancer cells proliferate and migrate in the nerve microenvironment. This type of invasion is exhibited by a variety of cancer types, and very frequently is found in pancreatic cancer. The microscopic size of nerve fibers within mouse pancreas renders the study of PNI difficult in orthotopic murine models. Here, we describe a heterotopic in vivo model of PNI, where we inject syngeneic pancreatic cancer cell line Panc02-H7 into the murine sciatic nerve. In this model, sciatic nerves of anesthetized mice are exposed and injected with cancer cells. The cancer cells invade in the nerves proximally toward the spinal cord from the point of injection. The invaded sciatic nerves are then extracted and processed with OCT for frozen sectioning. H&E and immunofluorescence staining of these sections allow quantification of both the degree of invasion and changes in protein expression. This model can be applied to a variety of studies on PNI given its versatility. Using mice with different genetic modifications and/or different types of cancer cells allows for investigation of the cellular and molecular mechanisms of PNI and for different cancer types. Furthermore, the effects of therapeutic agents on nerve invasion can be studied by applying treatment to these mice.

Targeting renal epithelial channels for the control of insect vectors.

Three small molecules were identified in high throughput screens that 1) block renal inward rectifier potassium (Kir) channels of Aedes aegypti expressed in HEK cells and Xenopus oocytes, 2) inhibit the secretion of KCl but not NaCl in isolated Malpighian tubules, and after injection into the hemolymph, 3) inhibit KCl excretion in vivo, and 4) render mosquitoes flightless or dead within 24h. Some mosquitoes had swollen abdomens at death consistent with renal failure. VU625, the most potent and promising small molecule for development as mosquitocide, inhibits AeKir1-mediated currents with an IC50 less than 100 nM. It is highly selective for AeKir1 over mammalian Kir channels, and it affects only 3 of 68 mammalian membrane proteins. These results document 1) renal failure as a new mode-of-action for mosquitocide development, 2) renal Kir channels as molecular target for inducing renal failure, and 3) the promise of the discovery and development of new species-specific insecticides.